[The following is based on a video recorded in August. It has been edited for clarity and space.]
| P A N E L I S T S | |
|---|---|
 | Bariatric and Minimally Invasive Surgeon Dr. Mona Misra Advanced Surgical Specialists Inc. Cedars-Sinai Medical Center Beverly Hills, Calif. |
 | Chair, Department of Surgery University of California Irvine Medical Center Immediate Past President, American Society of Metabolic and Bariatric Surgery Orange, Calif. |
 | Medical Director of Bariatric Surgery and Obesity Medicine CHI Memorial Hospital Past-President of the American Society for Metabolic and Bariatric Surgery Chattanooga, Tenn. |
 | Column Editor and ModeratorProfessor of Clinical Surgery, Chicago Medical School Rosalind Franklin University of Medicine and Science President, Chicago Institute of Advanced Surgery |
Rami Lutfi, MD (Column Editor): Hello everyone, my name is Dr. Rami Lutfi, and I am the editor of Surgical Economics, a column in which we tackle the business aspects of surgery—issues that affect surgeons every day. Today I’m honored to have three people who represent the three main types of surgical practice. We have Dr. Mona Misra, who is a pure private practitioner in Beverly Hills; Dr. Ninh Nguyen, who is in a major academic institution just next door in UC Irvine; and then last, but not least, is Dr. Jaime Ponce, who is well known in the bariatric and foregut world, who has just switched from private practice to being employed in a large system. Dr. Misra, maybe we’ll start with you.
Dr. Misra: Hello, I am Dr. Mona Misra. I am in private practice in Beverly Hills. I originally started in academic practice and then moved into private. I was an academic in Canada and then moved here and became a private practice surgeon, with bariatric surgery making up about 85% to 90% of the cases I do.
Dr. Lutfi: What is the main reason that made you enter private practice?
Dr. Misra: For me, it was time management and control. I wanted control over my life and my practice, and so this gave me some more flexibility. I loved it, and just want to stay in private practice as long as I possibly can.
Dr. Lutfi: Dr. Nguyen?
Dr. Nguyen: Thank you, Dr. Lutfi, for setting this up. This topic is of quite interest for many of our graduates and I am sure we’re going to learn a lot from this discussion. My name is Ninh Nguyen. I am the past president of the American Society of Metabolic and Bariatric Surgery (ASMBS), and I am currently the chair for the department of surgery at University of California, Irvine. My clinical practice is 50% bariatric surgery and 50% foregut surgery. I have been in an academic settings since I finished fellowship, so maybe I don’t know any better, and I am sure this discussion will enlighten me. The main reason that I went into academia is my interest in research and how we can continue to push forth the field of metabolic/bariatric and foregut surgery. So, as part of my clinical practice, I often participate in clinical trials, and hence that’s my main reason for going into an academic setting.
Dr. Lutfi: Excellent, thank you. Dr. Ponce?
Dr. Ponce: Thank you, Dr. Lutfi, and thank you for setting this up. I am a bariatric surgeon practicing in Chattanooga, Tenn., in a hospital system. It’s a Catholic hospital system network, CHI Memorial Hospital. I am a past president of the ASMBS—I was president before Dr. Nguyen. I’m also the current president of the North American chapter of the International Federation for the Surgery of Obesity and Metabolic Disorders.
I was in private practice for many years, until 2017, starting practice in 1999 in this area, and I was a part of a group of four surgeons. We were doing very well, everything looked good, we were practicing in two hospitals. Actually, it was not a typical private practice. I diversified myself to do research in clinical trials and I was excited to do presentations in the ASMBS and many other organizations. Eventually one of the hospital systems, the one in Chattanooga, offered me to become hospital employee and concentrate in their Hospital Bariatric Surgery program. Now, the big question is why? Why did I take that deal, and how did I decide that what I had was not as good as the deal that I have right now? Well, over time, as you probably all know, it was becoming more difficult to deal with all the administrative issues, staffing, and day-to-day challenges to run a private practice—all the business aspects, dealing with EMR [electronic medical record] compliance, the rising overhead costs, the difficulty getting insurance authorization, and so on. So, there was a good opportunity to concentrate in one hospital system, and I switched to hospital employment.
Dr. Lutfi: Excellent. General Surgery News is read by a wide range of surgeons in different stages of their careers. I’m in private practice in Chicago, but I started a surgical group that is now growing—we have our own fellowship and we’re very academic—with different specialties within the practice. Dr. Misra, tell us about the day-to-day of your practice—what’s good, what’s bad, what’s challenging for you? You talked about control—you don’t answer to anyone, so you can innovate without much bureaucracy within the limits of financials.
Dr. Misra: I have a very unique kind of practice, and I think it’s because of where I’m located. There is a lot of competition—we’re all kind of clumped together—everyone wants to be in [Los Angeles], Beverly Hills. Day-to-day, I am in multiple locations. I have privileges at Cedars-Sinai Medical Center as well as Cedars-Sinai Marina del Rey, where I’m the associate director of the program. I spend time at the hospital, but I’m also at different surgery centers and go to different locations in Southern California. So, for my day-to-day, I leave block time for everybody and they schedule my patients or surgeries based on that. I am in solo private practice—financially it’s all my show, and I get to make the decisions of who I’m hiring and what exactly my practice is going to be like. Fortunately, I have good relationships with other surgeons around me, so this helps with coverage, like attending courses and society meetings, for example. You do need the time, and you have that flexibility if you make good relationships to be able to do what you want to do.
I am also involved with research and teaching, and have residents and fellows that come and rotate with me in the hospital. I feel like I’ve gotten the best of all worlds here and that I have that control, but I also get to teach, and I get to be involved in research as much as I want. I get to be involved with the [ASMBS] which is important to me, and then also, I get to make time for family. I have a young child and am able to take off, an afternoon from time to time, and say, “Block off my afternoon because I want to listen to his 8-year-old poetry reading.” So, each day brings something new—some days I’m in the OR, sometimes I’m in the office, and it really just depends on what location, what they want to schedule for me. But the autonomy and flexibility and variety are very attractive. It’s a challenging type of a job, but it’s very rewarding.
Dr. Lutfi: I do want to comment that Mona is in private practice, and Jaime was in private practice and is now employed, and I’m in private practice, and we all have, to some extent, academic interests and input. And so, this is for the young people to know—that if you have an interest in academia, it does exist and is possible outside the confinement of the big universities; leadership roles as well. Having said that, the university does have a very different level of academics, and that’s a good segue to Dr. Nguyen. Ninh, tell us the overall good and bad of your life in your career.
Dr. Nguyen: So, I would say my day-to-day activity has changed dramatically since I became chair of the department of surgery. Previously, I served as the division chief of bariatric and GI surgery. Back then, it was mainly clinical (80%) with about 20% research. With this mixture of clinical versus research effort at UCI, I think that attracts a lot of our fellows with similar interest where they say, “I want to go into an environment where there’s some dedicated time to academics.” In private practice, I’m sure you can do research also, but the academic environment fosters collaboration and has readily available an infrastructure to perform the research. In addition, there is opportunity in an academic setting to be able to carve out protected time so you can actually devote yourself to research. These are some of the reasons why I was attracted to academic surgery. When I graduated from fellowship, I knew I wanted to be in a setting that would allow me to perform clinical trials, and at that time, I was embarking on a trial comparing laparoscopic versus open Roux-en-Y gastric bypass. I am sure I could have done that same trial in a private setting, but I will tell you that it would have been much more difficult to obtain the necessary resources, such as the help of a research coordinator, the help of a statistician, and even the ability to obtain funding to perform such a large clinical trial in the private setting. I would say that’s what academics will bring to the table—the ability for a surgeon, who has that keen interest, to do clinical trials.
My day-to-day activity completely changed when I took this position as chair of the department of surgery. Now, 50% of my time is devoted to administrative responsibilities in running the department and then the rest of the time is about 40% clinical and then 10% is research and participation in regional/national societies. So, it depends on the individual. Some people will say, “I am a clinician at heart and that’s what I want to do—I want to see patients and practice medicine.” Then there are others who want to evolve their careers and professional development to administration, and running a team, etc. and an academic setting allows you to do that.
Dr. Lutfi: That’s great, Ninh. I feel like I’m the same now that my group grew and we have multispecialty practitioners. I feel that a lot of that time, which usually is between 6 p.m. and midnight now, is devoted to managing all the finances and other things of our group. It definitely gets very tricky. Dr. Ponce, any other thoughts to add?
Dr. Ponce: Yes, it’s interesting to hear Mona and Ninh, because I’ve been in between those two settings. I can almost see myself where Mona is right now. I was there doing my private practice. I was going to two different hospitals, and a surgery center, and I was trying to manipulate my day—driving between hospitals about 30 to 40 minutes apart, depending on traffic, to manipulate my schedule—that was my life. We had a little bit of different mindset in my practice. We always took a day off for personal reasons, and my partners, sometimes they used it to do personal things. I started carving out that time for academic pursuits. It is true what Dr. Nguyen said: to do a research project within private practice is a lot more difficult—you don’t have the resources—and I was lucky enough to be pushy and get engaged with the hospital to provide some resources, but it is not as easy as if you are in an academic setting.
Moving now to a hospital employment, my life has become more focused in clinical care. I’m only going to one hospital; have a dedicated bariatric OR staff, with a comprehensive multidisciplinary team. The hospital takes care of the administrative aspects of the staff, and I concentrate on the clinical aspects of patient care. Staffing can be burdensome —as with Mona in private practice—and now the hospital can absorb that part of the practice. They provide our patients with the dietitian and with psychology support, and, in addition to that, I have the support to do research. The hospital healthcare system has a research department—has an IRB—so it’s very similar to an academic setting without the academic requirements of having to do research and produce academically. I don’t have to do it, I just do it because I can, so it’s a nice balance. I’m describing the good aspects, but there are some limitations as the hospital moves things different than private practice, with more compliance in marketing, social media, and are more conservative in making changes.
Dr. Lutfi: I must give warning, like the disclaimers at the end of TV commercials, to the young surgeons who are watching or reading: Dr. Ponce’s situation is the exception and not the rule. He earned a high-power position as an employed surgeon and therefore was able to negotiate a great contract. For most though, one major challenge in employment is the limited ability to have control over your practice. Numbers of hospital you have to operate in, number of cases you need to perform, and at times, the types of cases you are expected to do can change with time and without your approval. For example, an early career general surgeon with interest in GI surgery and hernia, maybe “pushed” to do breast surgery to fill for a surgeon on leave. And as far as the staff—while it’s Mona’s problem to find and hire staff when she decides—for you, Dr. Ponce, yes, someone else will do it for you, but that someone else needs to be convinced to hire that extra staff. If you go from 300 to 500 cases, your administrative boss, who likely has a much lower degree of education than you, may not feel there’s a need yet to hire more support staff to match your growth.
Dr. Ponce: You’re right, you lose some independence; you’re under the hospital control, but that’s why it becomes so important when young surgeons negotiate their contracts to make sure they have a supportive hospital administration—yes, we can talk about all those details Dr. Lutfi just mentioned [about loss of control], but, in general, if you set up your contract with the appropriate expectations, it has made many surgeons attracted to become employees and not “adventure” with the private practice issues.
Dr. Lutfi: Thank you, Dr. Ponce, very well said. Dr. Nguyen?
Dr. Nguyen: So, I have a question for the three of you. The one question I would say that’s on top of the minds of our fellows and residents approaching graduation and trying to select which practice they would like to enter, is the issue of compensation. Many of them say they will select their practice setting based on compensation, so from your standpoint, if a fellow is graduating and compensation is top of mind for them, what is your suggestions? What type of practice would you guide that person to?
Dr. Lutfi: Thank you, Ninh. I just gave a talk for fellows about job hunting, and I always warn flipping immediately through contract pages to Exhibit A where the final compensation number is stated. Everyone is under financial pressure with medical school loans and family and so forth, so of course [compensation] is very important, but I would say for those who are younger, look at the bigger things like mentorship, support if you get in trouble, and your future and potential in that practice. If you get a contract for $350,000 versus $320,000, that extra $30,000 may not be worth it when you have partners who do not appear to be supportive or even kind. So, I would look at an exit strategy, I would look at the day-to-day, I would look at all the details—for instance, if you think you’re smart enough to maybe invent something, you’re going to look at intellectual property. Also, you look at job restriction clause if you leave (especially if it is critical to you to stay in that area), liability insurance tail obligation, and whether or not you may have to pay back any money.
We’re starting a new division in my company for vascular surgery and I’m hiring vascular surgeons. We had a hiring consultant, and I was very surprised that private practice is no longer more financially attractive than academic to a large degree. If you start like Mona, you are definitely going to struggle financially initially, but then the sky is the limit. If you invest in a surgery center, you can grow your business. The people that I personally hire at the Chicago Institute of Advanced Surgery, get paid less than University of Chicago and Northwestern, but we provide our surgeons with tools for success that they can use effectively and largely increase their earning, while still enjoying control and flexibility. I feel academics is in the middle of road between employment and private practice in many aspects beyond the economics. The problem with employment as I said, is lack of control. Academic surgery remains the most straightforward—some university politics, but short of that, you mostly know what you’re going to get.
Dr. Misra: I think it’s such a great question. When I finished fellowship, it was 2005, and I went into academic practice, and I was happy I did that because it was kind of like an employed academic practice. It gives you that experience you need, so you can get good and get fast and better at all of the things that matter. You feel supported. If you’re doing a very complicated case, you have more senior surgeons who will help you out. It’s not competition, and so whether you’re employed or joining a private group, I think the first thing you want to do is make sure that you have good support. It helps develop you as a surgeon, because just finishing residency and maybe fellowship, even though you think you know everything, you don’t. You really want to get a little bit more time under your belt dealing with patients and understanding how to run a practice.
I would never recommend for someone to go straight into solo private practice. I think that is really challenging. You have to be very special in so many ways and have incredible skills in so many ways. And like Rami was saying, you don’t get paid right away—it’s like six months before you get any kind of insurance check. It’s challenging and your expenses are very high, and so having all that experience under your belt first—for me it was five years before I started private—I think that really helps because then you know what you’re looking for, you know what you need for staff, you know what you need for paperwork, you know how to deal with marketing, etc.
There’s so much to know first before you should consider going out on your own. It’ll save you a lot of headache and heartache. So that would be my recommendation: Go with people you trust and who you admire and who can mentor you, and then it will help you actually figure out which way you want to go because you may realize you want private or you may realize you thought you wanted private, but actually what you wanted was academic and you want to do major research. You’re just trying to figure out how to be a good surgeon through residency and fellowship, so I would say give yourself that time to figure things out.
Look for Part 2 of this conversation in next month’s issue. You can send questions or suggestions for future columns to khorty@mcmahonmed.com.
This article is from the October 2023 print issue.
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